K.M. Venkat Narayan: Diabetes: Has the Dragon trumped the Elephant?

venkat narayan“China pips India as the world’s most diabetic nation” ran the headlines in Hindustan Times (March 26, 2010).  It almost sounded as if India’s pride had been hurt. Such a deep sense of defeat was not expressed even when China led the world winning 51 gold medals to India’s one and only in the 2008 Olympic Games!

Never mind the Olympics. With an estimated 50 million people with diabetes, India had stubbornly held on to the infamous title of the “diabetes capital of the world”.  A recent study – of 46,000 adults from a nationally representative sample – published in the New England Journal of Medicine (March 25, 2010) has, however, estimated 92 million people with diabetes in China, and an additional 150 million with “prediabetes” and at high risk of developing it. 
These data are alarming, and are likely to totally overwhelm earlier projections by the International Diabetes Federation of 435 million people with diabetes world-wide by 2030.  What is particularly disturbing about these data is the very high rural diabetes prevalence; with 11.4% of urban residents and 8.2% of rural residents in China having the disease.

High diabetes rates have been considered an urban phenomenon world-wide, and as affecting mainly the affluent middle-class in rapidly growing emerging economies.  But these assumptions may no longer be true.  As the China study shows, diabetes does not spare rural populations or poorer people in developing countries. The forces causing the type 2 diabetes epidemic – physical inactivity, sedentary lifestyle, unhealthy nutrition – seem ubiquitous and all pervasive, as globalization spreads conferring its economic benefits and at the same time exacting its toll with diseases such as diabetes.

Why has China overtaken India to become the “world’s new diabetes capital?” 

I am not sure it has. The prevalence of diabetes in urban India is hovering around 16-18%, much higher than the 11.4% in China. Estimates of numbers of people with diabetes in India, however, have assumed far lower rural prevalence than was found in China.  Nationally representative rural diabetes data are not available for India.  With seventy percent of the population still living in rural India, small increases in rural diabetes prevalence can very substantially impact the total numbers.  A well-designed nationally representative survey is needed to accurately estimate the numbers with diabetes in India. 

More importantly, China, India, and other rapidly evolving economies need to take aggressive steps to stem the diabetes epidemic before it swamps their human and economic capital.  Policies to make environments conducive to physical activity and to reduce availability of high-calorie processed foods should be explored.

At the same time, strong evidence from several clinical trials (from the US, Finland, China, India) indicate that structured lifestyle interventions targeted at people with (pre-diabetic) high glucose levels can substantially prevent or delay progression to diabetes.  Programs to identify such high risk individuals and to deliver lifestyle interventions to them at low-cost are needed urgently.

China and India are in an exciting twenty-first century race for global stardom. This race need not be about who will be the “world’s diabetes capital.”

 To ensure that, both the Chinese Dragon and the Indian Elephant need to implement diabetes prevention and control policies soon. The clock is ticking away!

K.M. Venkat Narayan is Ruth and O.C. Hubert Professor of Global Health and Professor of Epidemiology and Medicine at Emory University Atlanta. He is a product of three continents, having lived and worked in India, United Arab Emirates, United Kingdom, and United States of America.